Session-6 The DSM-5: Overview of Main Themes and Diagnostic Revisions Flashcards
When was the DSM-IV-TR first issued?
It was first issued in 1994, 968 pages long.
When was the DSM-IV-TR first revised?
It was first revised in 2000, 988 pages long.
When was the DSM-5 initiated?
Update initiated in 1999 and finally published on May 17, 2013, 947 pages long.
What are the DSM-5 sections of the manual?
Section I: Introduction and information on how to use the manual.
Section II: Diagnostic criteria and codes
Section III: Emerging measures and models, conditions that require further research, a glossary, cultural concepts of distress, and names of persons involved in the manual’s development. (where all the new stuff they are adding is located).
Appendix.
How was the DSM-5 developed?
APA organized groups of experts in distinct areas to assess diagnostic categories and disorders;
Came up with consensus viewpoints on symptomatic descriptors;
Field-tested new descriptors to determine revised diagnostic criteria (cluster sets and thresholds).
Presented to APA Board Trustees for sign-off
note: The development of it was political, the way they are supposed to be revised is that they are suppose to do more and more research, they look at patients and do all these analysis. But basically they end up in a room and a political process takes place, representatives from the pharmaceutical companies are connected to the final decision.
What were the primary goals of DSM-5 Task Force in creating the new manual?
Increase cultural sensitivity;
Deepen the clinician’s understanding of the client;
Increase awareness of the neurobiology underpinning mental disorders;
Appraise the role of social and contextual factors associated with psychiatric symptoms.
note:
Neurobiology (bottom-up approach)
Case conceptualization- intra-psychic and contextual factors
What was the first major change to DSM-5?
The multiaxial system has been abandoned.
Axes I, II, and III have been combined.
All clinical disorders are simply listed in order of priority (no real hierarchy of axes implied).
No more GAF (people tended to use very idiosyncratically, and did not follow the symptom severity x impairment rating codes)
What was the second major change to DSM-5?
Incorporate a Spectrum Perspective (based on groupings that reside under the same family)
DSM-5 change to Incorporate a Spectrum Perspective was based on what two emerging realizations?
Based on two emerging realizations in the field:
(1) There is not much evidence that disorders are actually categorically distinct from one another (both within and across diagnostic categories)
(2) The distinction between “normal” and “abnormal” behavior is ultimately, arbitrary.
DSM-5 Incorporate a Spectrum Perspective; OCD was repositioned in what category?
Example: OCD is removed from the “Anxiety Disorders” category (DSM-IV-TR) and repositioned in a new category called “Obsessive-Compulsive and Related Disorders” (DSM-5).
The beam of light going into the prism (underlying core factor of anxiety) splits into several separate but related diagnostic categories.
DSM-5 Incorporate a Spectrum Perspective; The 20 newly-refined diagnostic categories of mental disorders depict…?
updated groupings of all disorders, with each grouping sharing similar characteristics.
note:
Has resulted in a fair amount of reshuffling of the deck, e.g., “Neurodevelopmental Disorders” (includes Autism Spectrum Disorder, ADHD, and other disorders reflecting
abnormal brain development).
What is the third major change to DSM-5?
Incorporate Dimensionality
Diagnostic thresholds (categorical/qualitative) are now supplemented by the degree to which the diagnosis is present (dimensional/quantitative).
Severity ratings (from minimal to more extreme levels): typically, symptom counts.
What is the fourth major change to DSM-5?
Reflect a developmental perspective:
(1) Chapter structure of DSM-5 follows a neurodevelopmental life span approach (congruent with the system used by the ICD [World Health Organization]):
Early development: Neurodevelopmental Disorders; Schizophrenia Spectrum and Other Psychotic Disorders; etc.
Adolescence/early adulthood: Depressive Disorders; Anxiety Disorders; etc.
Later life: Neurocognitive Disorders.
note: The way dsm-5 is organized, in the beginning you have the early developmental..etc. they arranged it so that it is developmentaly congruent with the path of life.
(2) For specific disorders, variations of symptom presentations across the lifespan are described.
What is the fifth major change to DSM-5?
Increase the emphasis on culture and gender.
Cultural information and gender differences are included wherever relevant.
Previous cultural formulation replaced with the Cultural Formulation Interview (CFI; pp. 750-757), a structured clinical interview that assesses the client’s subjective view of cultural factors re: the presentation of symptoms (effort is to diminish the clinician’s own cultural biases).
What is the sixth major change to DSM-5?
Enhance Descriptive Information for Diagnoses:
Many specifiers provided.
Severity ratings provided.
Not Otherwise Specified (NOS) deleted, but here is what they came up with instead: if not meet full criteria for the disorder use “Other Specified” (need to give a reason) or “Unspecified Disorder” (don’t need to give a reason).
What is the 7th major change to DSM-5?
Match the international classification of diseases (ICD) Codes
DSM-5 includes equivalent ICD-9 and ICD-10 codes.
The U.S. will adopt the ICD-10 in October, 2014; however, by that time, most of the world will already be using ICD-11.
note:
ICD codes is the medical world, most of DSM-5 matches ICD-10
What is the 8th major change to DSM-5?
Reinvent DSM to be a “living” document:
DSM-5 (Arabic numeral) vs. DSM-IV-TR (Roman numeral).
More readily incorporate advances generated by new research, neuroscience, and investigations re: the genetics of psychiatric illness.
What is the 9th major change to DSM-5?
Introduce the potential of the so-called “hybrid” model in subsequent DSMs
Do Personality Disorders remain the same in DSM-5 as in DSM-IV-TR?
The Personality Disorders (PDs) essentially remain the same in DSM-5 as in DSM-IV-TR.
Section III of DSM-5 introduces a hybrid…?
Introduces a hybrid (category and dimensional synthesized) model of PDs:
Level of impairment of personality functioning (dimensional) with ….
An evaluation of personality traits (categorical)
note: “whodaf”? Measures new measure like the GAF measure
Personality disorders have a combo of category and dimensionality. 4-TR based with category
DSM-5: What are the five broad domains of personality traits?
(1) Negative Affectivity
(2) Detachment
(3) Antagonism
(4) Disinhibition
(5) Psychoticism
note: As a field, we are moving closer to defining what the core elements of psychiatric health/personality actually are
What is the tenth major change to DSM-5?
Use biologically-based diagnostic criteria:
For some disorders, DSM-5 employs objective measures (genetic work-ups, neuroimaging, neurochemistry) into the criteria sets.
David Kupfer, M.D., the co-chair of the DSM-5 Task Force, indicated a keen interest in genetic tests/brain scanning/biomarkers/laboratory tests, but admitted that the field is not quite there yet.
note: He basically says the dSM-5 was disappointing, they wanted more diagnostic criteria to have more biologically based content in it, like blood tests and things and he is upset that a lot of it is still like psychological systems. He is saying I want 2929 to come now, this field wants to go towards scanning the fetus.
DSM-5:
“Neurodevelopmental Disorders”
Intellectual Disabilities
Communication Disorders
Autism Spectrum Disorder
Attention-Deficit/Hyperactivity Disorder
Specific Learning Disorder
Motor Disorders
Other Neurodevelopmental Disorders
note: The title- diagnostic category, used to be called disorders usually first diagnosed in infancy, childhood and adolescence
DSM-5: “Neurodevelopmental Disorders” : shifts
Separation Anxiety used to be in ____ now in____.
Separation Anxiety used to be in (DSM-IV-TR) “Disorders Usually First Diagnosed in Infancy, Childhood and Adolescence” and is now in (DSM-5) “Anxiety Disorders”
DSM-5: “Neurodevelopmental Disorders” : shifts
Selective Mutism used to be in ___ now in___.
Selective Mutism used to be in (DSM-IV-TR) “Disorders usually first diagnosed in Infancy, Childhood and Adolescence” and is now in (DSM-5) “Anxiety Disorders”
DSM-5:
“Schizophrenia Spectrum and Other Psychotic Disorders”
Schizotypal (Personality)
Disorder
Delusional Disorder
Brief Psychotic Disorder
Schizophreniform Disorder
Schizophrenia
Schizoaffective Disorder
Substance/Medication-Induced
Psychotic Disorder
Psychotic Disorder Due to Another Medical Condition
Catatonia
Other/Unspecified
DSM-5: “Schizophrenia Spectrum and Other Psychotic Disorders” Shifts
Schizotypal (Personality) Disorder used to be in _____ now in ____.
Schizotypal (Personality) Disorder used to be in (DSM-IV-TR) Axis II Personality Disorders and is now in (DSM-5) “Schizophrenia Spectrum and Other Psychotic Disorders” and “Personality Disorders”
DSM-5: “Schizophrenia Spectrum and Other Psychotic Disorders” Shifts
Schizophrenia Disorder used to be in _____ now in ____.
Schizophrenia subtypes in (DSM-IV-TR) used to include “Paranoid, Disorganized, Catatonic, undifferentiated, and residual” and in (DSM-5) the subtypes are removed.
note: Inter-rater reliability was poor- you take 100 experienced clinicians give them the DSM-IV-TR and give them 1000 schizo patients the degree to which they say what subtype they are is very poor-either we don’t have the right descriptions or they are really poor, so they just eliminated them
In the DSM-5 for “Schizophrenia Spectrum and Other Psychotic Disorders” is there greater emphasis on positive or negative symptoms?
DSM-5 minimizes importance of negative symptoms; emphasis is more on positive symptoms.
DSM-5 for “Schizophrenia Spectrum and Other Psychotic Disorders” can now specify?
Can now specify severity (how many symptoms the person has): see dimensional rating scale “Clinician-Rated Dimensions of Psychosis Symptom Severity” in Section III of the DSM-5 Manual (pp. 742-744).
DSM-5 “Schizophrenia Spectrum and Other Psychotic Disorders” diagnostic criteria must maintain..?
Delusions, hallucinations, disordered thinking (speech), and grossly disorganized or abnormal motor behavior (including catatonia) maintained.
DSM-5:
“Bipolar and Related Disorders”
Bipolar I Disorder
Bipolar II Disorder
Cyclothymic Disorder
Substance/Medication-Induced
Bipolar and Related Disorder
Bipolar and Related Disorder
Due to Another Medical Condition
Other and Unspecified
DSM-5: “Bipolar and Related Disorders”: Shifts
Depressive Disorders and Bipolar Disorders no longer listed under the umbrella category of “Mood Disorders” (as was the case in DSM-IV-TR).
DSM-5: “Bipolar and Related Disorders” note on primary criteria and specifier added?
The primary criteria for manic and hypomanic episodes now include an emphasis on changes in activity and energy as well as mood.
More specifiers added (p. 127):
e.g., “With anxious distress”: capture anxiety symptoms.
DSM-5:
“Depressive Disorders”
Disruptive Mood
Dysregulation Disorder
Major Depressive Disorder
Persistent Depressive Disorder (Dysthymia)
Premenstrual Dysphoric Disorder (*new family member)
Substance/Medication-Induced
Depressive Disorder
Other and Unspecified
DSM-5: “Depressive Disorders”: Shifts
Disruptive Mood Dysregulation Disorder
Premenstrual Dysphoric Disorder
Persistent Depressive Disorder (Dysthymia)
Bereavement
Disruptive Mood Dysregulation Disorder is new and now in (DSM-5) “Depressive Disorders”
Premenstrual Dysphoric Disorder used to be in (DSM-IV-TR) “Disorders in Need of Further Research” and now in (DSM-5) “Depressive Disorders”
Persistent Depressive Disorder (Dysthymia) used to be (DSM-IV-TR) “Dysthymic Disorder” in the “Depressive Disorders” subcategory of Mood Disorders and now in (DSM-5) “Depressive Disorders”
Bereavement used to be (DSM-IV-TR) V62.82 Major Depressive Disorder (MDD count not be diagnosed if symptoms were due to loss) and now in (DSM-5) MDD diagnosed even if symptoms are related to grief
In DSM-5: How is an MDE with 3 manic symptoms coded?
A major depressive episode with at least 3 manic symptoms is now coded with the specifier “with mixed features”
In DSM-5: What used to be known as “double depression”?
Persistent Depressive Disorder (Dysthymia): what used to be known as “double depression” (refractory major depressive episodes along with chronic sub-threshold depressive symptoms).
DSM-5: What is a controversy with DMDD?
DMDD: Are we fostering the pathologizing of temper outbursts?
DSM-5: What is a controversy with bereavement exclusion for MDD?
Removal of the bereavement exclusion for MDD: Are we over-pathologizing the normal bereavement process?
note: the threshold for getting disorders is getting lower and lower.
DSM-5:
“Anxiety Disorders”
Separation Anxiety
Selective Mutism
Specific Phobia
Social Anxiety Disorder (Social Phobia)
Panic Disorder
Agoraphobia
Generalized Anxiety Disorder
Substance/Medication-Induced
Anxiety Disorder
Other and Unspecified
note: anxiety disorders use to be part of mood disorders
DSM-5: “Anxiety Disorders”: Shifts
Separation Anxiety Disorder
Selective Mutism
Agoraphobia
OCD
Acute Stress Disorder
PTSD
Body Dysmorphic Disorder
Separation Anxiety Disorder used to be in (DSM-IV-TR) “Disorders Usually First Diagnosed in Infancy, Childhood and Adolescence” and now in (DSM-5) “Anxiety Disorders”
Selective Mutism used to be in (DSM-IV-TR) “Disorders Usually First Diagnosed in Infancy, Childhood and Adolescence” and now in (DSM-5) “Anxiety Disorders”
Agoraphobia used to be in (DSM-IV-TR) “Panic Disorder without agoraphobia and agoraphobia with or without panic disorder in “Anxiety Disorders” and now in (DSM-5) “panic disorder and agoraphobia de-linked but still fall under “Anxiety Disorders”
OCD used to be in (DSM-IV-TR) “Anxiety Disorders” and now in (DSM-5) “Obsessive Compulsive and Related Disorders”
Acute Stress Disorder used to be in (DSM-IV-TR) “Anxiety Disorders” and now in (DSM-5) “Trauma and Stressor- Related Disorders”
PTSD used to be in (DSM-IV-TR) “Anxiety Disorders” and now in (DSM-5) “trauma and stressor- related disorders”
Body Dysmorphic Disorder used to be in (DSM-IV-TR) “somatoform disorders” and now in (DSM-5) “obsessive compulsive and related disorders”
DSM-5:
GAD symptom duration was lowered from 6 to..?
Symptom duration lowered from 6 to 3 months
DSM-5:
GAD associated symptoms of anxiety and worry lowered from 3 to..?
Associated symptoms of anxiety and worry lowered from 3 to 1 symptoms needed
note: Aaron Beck indicated this will result in a rise of “false positive” GAD diagnoses.
DSM-5:
“Trauma- and Stressor- Related Disorders”
Reactive Attachment Disorder
Disinhibited Social Engagement Disorder
PTSD
Acute Stress Disorder
Adjustment Disorders
Other and Unspecified
DSM-5: “Trauma- and Stressor- Related Disorders”: Shifts
Reactive Attachment Disorder
Disinhibited Social Engagement Disorder
PTSD
Acute Stress Disorder
Adjustment Disorders
Reactive Attachment Disorder used to be in (DSM-IV-TR) “Disorders usually first diagnosed in infancy, childhood, and adolescence” and now in (DSM-5) “trauma and stressor related disorders”
Disinhibited Social Engagement Disorder is a new disorder (DSM-5) in “trauma and stressor related disorders”
PTSD used to be in (DSM-IV-TR) “anxiety disorders” and now in (DSM-5) “trauma and stressor related disorders”
Acute Stress Disorder used to be in (DSM-IV-TR) “anxiety disorders” and now in (DSM-5) “trauma and stressor related disorders”
Adjustment Disorders used to be in (DSM-IV-TR) “adjustment disorders” and now in (DSM-5) “trauma and stressor related disorders”
DSM-5: Are adjustment disorders a residual category?
Adjustment Disorders no longer a residual category (DSM-IV-TR subtypes retained)
DSM-5: What two disorders are the result of a social neglect or other situation that limits a young child’s opportunity to form selective attachments?
Reactive Attachment Disorder and Disinhibited Social Engagement Disorder (resembles ADHD)
DSM-5: PTSD note?
For PTSD, attempted to specify “trauma” as an actual or threatened death, serious injury or sexual violation
DSM-5: What controversy on “trauma and stressor related disorders”?
New criteria (i.e., “Emotional reactions to the traumatic event [fear, helplessness, horror]” [p. 274] no longer being necessary) may dilute what is actually deemed “traumatic.”
Diagnosis may occur for people who have not had direct exposure but merely learned about a violent traumatic event suffered by a loved one
DSM-5:
“Substance Related and Addictive Disorders”
Substance Use Disorders
Alcohol-Related Disorders
Caffeine-Related Disorders
Cannabis-Related Disorders
Hallucinogen-Related Disorders
Inhalant-Related Disorders
Opioid-Related Disorders
Sedative-, Hypnotic-, and Anxiolytic-Related Disorders
Stimulant-Related Disorders
Tobacco-Related Disorders
Non-Substance-Related
Disorders (Gambling Disorder)
DSM-5: What changes were made to “substance related and addictive disorders”?
“Abuse” and “dependence” have been collapsed into a single diagnostic category (addictions exist on a continuum: the spectrum perspective).
Severity of diagnoses (dimensionality) rated as mild, moderate, or severe, based on the number of symptoms.
note:
Love addiction, pornography, and sex addiction are now known as process addictions.
“First-time substance abusers are now lumped together with heroine addicts” (Zur Institute);
Category has been expanded beyond psychoactive substances (controversy)
DSM-5:
“Neurocognitive Disorders”
Delirium
Major Neurocognitive Disorder (with Etiological Subtypes) Alzheimer’s Disease Vascular Disease Traumatic Brain Injury HIV Infections Parkinson’s Disease Huntington’s Disease Substance/Medication.
Mild Neurocognitive Disorder (specifiers correspond to the disease process to which the cognitive decline is due)
note:
Formerly categorized in the DSM-IV-TR under the diagnostic category “Delirium, Dementia, and Amnestic and Other Cognitive Disorders.”
(controversy): Mild Neurocognitive Disorder: Are we pathologizing natural aging processes?
What is the distinction between illness and average expected generative decline?
What is the Section III of the DSM-5?
Emerging Measures and Models
note: This is the experimental section, in DSM-6 this information will make new entries. Let make up some measures that are cutting across different diagnostic disorders
- Assessment measures
- alternate DSM-5 Model for Personality Disorders (The hybrid Model)
- Conditions for further study
DSM-5: #1 What are Assessment Measures?
“Cross-cutting Symptom Measure”: Basically, instead of thinking about a diagnostic disorder they are coming up with these measures that assess problematic symptom disorders, forget if this kid has adhd, major depressive disorder, odd, forget that, lets just do a symptom assessment. The bottom up approach, we really care about the symptoms they have.
“Clinician-Rated Dimensions of Psychosis Symptom Severity”
DSM-5: #1 Emerging Measures and Models, what is replacing the GAF?
World Health Organization Disability Assessment Schedule 2.0 (WHODAS)
Understanding and communicating
Getting around
Self-care
Getting along with people
Life activities (household, work, or school)
Participation in society
DSM-5: #3 What are the conditions for further study?
Attenuated Psychosis Syndrome
Depressive Episodes with Short-Duration Hypomania
Persistent Complex Bereavement Disorder
Internet Gaming Disorder
Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure
Suicidal Behavior Disorder
Nonsuicidal Self-injury
DSM-5: What are the five major controversies?
- will we overdiagnose with the DSM-5?
- Are DSM-5 Diagnoses Valid?
- Was the Process of Development of the Manual Flawed?
- Are the DSM-5 Diagnoses Irrelevant to the Cause and Treatment of Psychological Problems?
- Is the DSM Experiencing an Identity Crisis?
- will we overdiagnose with the DSM-5?
The dimensional perspective has a risk of over-pathologizing (i.e., pathologize normal behavior and/or normalize pathologic symptoms); usually referred to as the “reduced threshold” problem.
May lead to stigma/mislabeling of those who would do better without a psychiatric diagnosis
- Are DSM-5 Diagnoses Valid?
Allen Frances: DSM-5 introduces new, invalid diagnoses and contends the DSM-5 Task Force is merely helping the drug companies
National Institute of Mental Health (NIMH) director Thomas Insel announced that it would no longer use DSM diagnoses in research projects due to the manual’s lack of validity.
He contends the manual should be used solely as a dictionary so that clinicians share the same descriptions of symptoms.
Research indicates that 2 clinicians agree on a diagnosis of major depression only 60 percent of the time (Zur Institute)
- Was the Process of Development of the Manual Flawed?
Development was shrouded in secrecy; changes were not empirically supported.
Were the work groups merely flying by seat of their pants?
DSM-5 diagnoses are based on a consensus about clusters of clinical symptoms, not on any objective laboratory measure (in medicine: symptoms rarely indicate the best choice of treatment)
- Are the DSM-5 Diagnoses Irrelevant to the Cause and Treatment of Psychological Problems?
Despite changes in the DSM-5, it remains “a topographical symptom map” (Zur Institute): does not capture causal pathways that give rise to and maintain illness.
- Is the DSM Experiencing an Identity Crisis?
It is not clear if the DSM-5 is a diagnostic tool, a treatment tool, a research tool, or some combination of all of these: Is the DSM a good example of Multiple Personality Disorder?
Different groups use the DSM too loosely or too rigidly (little pragmatic consensus); Traditionally it was in place to help clinicians diagnose and research, “The three phase of Eve”
How, in What Ways, for What Patients, under What Therapeutic Conditions Does Diagnostic Nomenclature Help or Hinder?
Best diagnostic tool is psychotherapy!
